Provider Demographics
NPI:1013097559
Name:PETERS, JOSEPH I JR (LCSW-R)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:I
Last Name:PETERS
Suffix:JR
Gender:M
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 W PEARL ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NY
Mailing Address - Zip Code:14513-1063
Mailing Address - Country:US
Mailing Address - Phone:315-331-5659
Mailing Address - Fax:315-331-5959
Practice Address - Street 1:145 W PEARL ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513-1063
Practice Address - Country:US
Practice Address - Phone:315-331-5659
Practice Address - Fax:315-331-5959
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0396761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYIA0871Medicare PIN